Interview Mike Carroll

Carroll is the head athletic trainer and the assistant athletic director at Stephenville High School in Stephenville, Texas. He warns that relying on coaches to assess a player's health is a dangerous conflict of interest. "The athletic trainer at the secondary-school level is really the most important person to have to care for the kids," he tells FRONTLINE. "And I just don't think a coach can do that." This is the edited transcript of an interview conducted on Nov. 15, 2010.

• Why more high schools don't have athletic trainers
• Coaches vs. athletic trainers
• Changing football terminology -- and culture
• The problem of parents "doctor shopping"

What percentage of schools in Texas require athletic trainers? And what are the national numbers on that?

In the state of Texas there's not a requirement anywhere for athletic trainers. Now, our state is different a little bit, because in Texas we were the first state in the United States to have licensure for athletic trainers. So we're coming up on the 40th anniversary of licensure. In 1971 we started that, so in the secondary-school level, we've had athletic trainers for a long time.

The numbers are really pretty good. At the 5A level, which is our biggest classification, every high school has at least one athletic trainer. Most of them have two; some have three; some have four. The 4A level is the same thing; that's our second biggest classification. All schools have an athletic trainer. The 3A level, which is kind of the middle classification -- it goes from 950 students down to about 400 -- they're about 60 percent, and that number is getting bigger every year. Ten years ago the number of 3A schools with an athletic trainer was less than 50 percent; now it's up to 60 [percent]. 2A and 1A, which are small schools, less than 300 students, it's probably 10 percent. So the number of schools with athletic trainers in Texas overall out of the 1,300 public schools is probably 600 or 700 of them. I bet you it's over 50 percent.

... The NATA is the National Athletic Trainers' Association. It's our membership association, and it's based out of Dallas, Texas. ... The national level, the number that the NATA uses, is about 40 to 45 percent of schools have access to an athletic trainer, which means that they can call somebody or an athletic trainer comes by one day a week. That counts the same as, say, our high school, which has two full-time athletic trainers. ...

Right. And this is for games and practices?

Here we do for games and practices. Schools, the number that NATA uses is just at some point during the week access. So there's never really been a definitive study that showed the number of schools that have an athletic trainer for all practices and games.

... Any schools in any state require athletic trainers for practices and games?

... The state of Hawaii, I think, has 100 percent of the public schools with an athletic trainer, but I don't know if that's legislated or why that is. District of Columbia public schools, they do have to have an athletic trainer at every sporting event, and that is a requirement. The state of North Carolina has a requirement that there has to be an athletic trainer or first aid provider. So yeah, you'd like to think that there would be an athletic trainer at everything, but from what I understand, some schools just don't do that.

And why don't they do that? Is it due to cost or other factors?

Why don't schools have athletic trainers? That's something I've been fighting for at least 10 years, since I was on the secondary-school committee. But I think a lot of times schools like to think that it's a cost issue, and with finances not getting any better anywhere, I think that's a copout. I think that's an easy fallback position. We don't have the money to have an athletic trainer. But I think a lot of times, if a school wants an athletic trainer, they can figure out a way to make it work, because if you have football, in my opinion, you need to have an athletic trainer. And if you can afford to pay football coaches, then you can afford to pay an athletic trainer.

Are there some cases where schools are choosing other additional elements to their programs above an athletic trainer? For example, do you see people spending money on turf fields or indoor practice facilities with money that could go to an athletic trainer?

Unfortunately, there are schools that use their resources to do things for their athletic department or their athletic program in ways that they could use it to have an athletic trainer. In fact, there is a school not very far from here, I think it was about 10 years ago, they got a new football coach in, and they had had an athletic trainer position at the school. This coach wanted to get another coach on his staff, and the superintendent told him that he could either hire another football coach or he could rehire his athletic trainer, and unfortunately he chose the football coach. So that school went without an athletic trainer for two or three years, which to me is shortsighted. You really need to have somebody at your school that is trained in prevention, treatment and care of athletic injuries, and no freshman football coach or no football coach, period, is going to be able to do that.

Do you think that that trade-off is common?

I don't think it's common. I think it happens more than it should, but I don't know that it's a common trade-off. But I just know that some people's priorities are not -- they don't see the big picture, I guess.

What is the argument for having an athletic trainer instead of having a coach perform that duty?

The argument for having an athletic trainer instead of having a coach take care of the injuries is that the athletic trainer has gone to school, has a degree, has certification over state licensure to do what they're doing, and they've taken a lot of coursework, and that's what they're trained to do; that's their profession. And it's not just someone that maybe took a class or that's their assignment from the head football coach. ...

I also think it's a conflict of interest for a coach that is potentially an assistant who has been evaluated by the head coach to make decisions about a kid's health -- whether or not he can go back into the game and if he's holding a kid out based on whatever minimal knowledge that he may have about that particular injury that the head coach could be upset with him because it may be one of his good players, and the athletic trainer is not going to make that same decision.

You've been on high school football for a while. Do you think there's more pressure nowadays for coaches to win?

... I think depending on where you are, yes. There's a high school just north of Dallas. ... Allen High School is building a $60 million football stadium. I think when you build a $60 million football stadium, there's a lot of pressure that the product on the field needs to be good, because you're going to want to put people in those seats of that $60 million stadium. ...

I think when high school football is being televised, when there's all these websites and message boards and in today's Internet age and in today's age where there's just so much exposure, things that used to kind of go by the wayside or people didn't notice, now they do, and I think that adds to the pressure that the coaches feel.

There seems to be a conflict of interest issue: the pressure on the coach to win. Does that make it more difficult for coaches? Does it make it even more problematic for coaches to make return-to-play decisions?

Yeah. I think anytime you throw in outside issues such as the wanting to win to get to the playoffs or keep your job or whatever that is, ... that may cloud their judgment. But it still goes back to [the fact that] coaches are not trained to recognize the signs and symptoms of injuries, and whether it be a spleen injury or a concussion or staph or a sprained ankle, they're just not trained for that, and you're putting them in a bad situation by asking them to make decisions based on that. I just think that the athletic trainer at the secondary-school level is really the most important person to have to care for the kids. I just don't think a coach can do that.

Their focus is elsewhere.

Their focus is elsewhere, and that's not what they want to do. You're asking someone to do something that they weren't trained to do, they didn't educate themselves to do. And it wouldn't be fair to ask me to be a football coach, because that's not what my focus is. I watch a lot of football; it doesn't mean I understand it enough to be able to coach it.

... Are you getting a sense that right now, the philosophy of having more certified athletic trainers in schools, specifically for high school football programs, is taking off in Texas and Arkansas?

The philosophy of having a certified or licensed athletic trainer I think has always been strong here [in Texas]. It's getting stronger. It's filtering down to the smaller schools. Arkansas has really -- it's taken off. They've grown six- or sevenfold in the last decade, just in the number of athletic trainers that they have.

I just think it's interesting: My very first job when I was hired in 1991, I was interviewed by a gentlemen that didn't see the value in athletic trainers, called us "trainers," you know. Reminded me all the time when he coached they didn't have trainers, and they taped their own ankles. And that was what he thought athletic trainers did, was they just taped ankles. And there were a lot of those people out there that were in athletic administrator jobs, and unfortunately, that kind of kept our profession from growing at the secondary-school level. But those guys are gone now; they're retired, and they moved on. And what's happened now, what I have seen a lot is that is the athletic administrators have almost not ever been in a school that didn't have an athletic trainer. So that's why, when they go into a school that potentially doesn't have one, they want to get one, because the smart ones know that they don't want to do our job. They don't want to have that liability. They don't want to have that responsibility. ...

Can you tell me where Arkansas was with the athletic trainers in schools a decade ago and where they are now numbers-wise?

In 1999, the state of Arkansas had seven full-time athletic trainers out of -- I think they have 340-some-odd high schools. So you do the math: Seven out of 344 is not very good. And now, 2010, basically a decade later, they've got over 50. So they've gone up 700 percent, ... and they even have a high school that has two athletic trainers.

So where they were and where they are now is just really -- they've come light years. They have some great legislation coming up there. They are doing some great things with injury surveillance, and Arkansas is really kind of moving to the forefront on education of their coaches, and they're trying to do some things up there that will get athletic trainers into schools and make sure that somebody's taking care of their kids, too.

But they're still only at something like only 15 percent of athletic trainers in schools. How does that square with the national average?

Arkansas is still below the national average, but they are getting a lot closer to it. The thousand-mile journey starts with one step. You can't go from seven athletic trainers to 50 in a year or even 10 years, but you can start moving in that direction. And what I think they have done is they are starting to move in that direction, and they are doing it at a pretty fast clip over the last decade.

Why is it so hard, though?

I don't pretend to understand the economics of other states' educational systems or even their mentalities, but I know Arkansas is a state that is largely rural, and I think a lot of times, cutting-edge stuff doesn't necessarily trickle down to the rural areas as fast as it does in the cities. And basically, Arkansas has got three or four kind of big cities, and then everything else is what most people would consider a small town. ...

How many schools that you are aware of have athletic trainers for just games versus practices? Is there a problem with that distinction between games and practices?

I think the problem with having an athletic trainer just for a game, ... they're showing up, they don't have the relationship with the kids; they don't have the relationship with the coaches. And a lot of injuries -- I don't know about most -- a lot of injuries happen during the week. And if you're showing up for a game, and you don't know anything about the injury, and you don't know anything about the progression that the student has had, even if you saw the injury the previous week, it makes it difficult. It makes the job harder.

I worked at a clinic for three years of my career, and during those three years, I had a contract with a high school, and I was out there two days a week plus Friday night games. And it just made it harder to understand what was going on in the kids' lives, or just even to follow a simple ankle sprain, whether it was that or a concussion, or you just didn't know what was going on when you weren't there.

I'm curious if kids, specifically high school football players -- do you notice them getting bigger and faster and stronger, and if so, why is that happening?

I absolutely think that high school football players are getting bigger and faster and stronger. We have a football coach on our staff that graduated from high school 35 years ago, and he played offensive line when he was in high school, and he said he weighed 165 pounds. If you weigh 165 pounds now, you're probably not going to play at all, but if you are, you're a receiver or you're a cornerback.

Our offensive linemen right now range between 220 and 270 pounds, and that's pretty normal for our size school. We played a team a couple weeks ago that had a defensive lineman that weighs 305 pounds and is committed to a Big 12 school. So, I mean, they're getting bigger; they're getting faster because of the training. They work year round.

Back in the old school days, I think they played football, and then they went to basketball, and then they went to baseball. And weightlifting wasn't anything that they really did, and they didn't work on strength and flexibility and improving their speed. And now we're doing all that with our kids. And because they are bigger and faster and stronger, they move faster. And it's simple physics: When two objects are very big and they're moving at high rates of speed, sometimes things happen. Ligaments tear, and brains get bruised -- you know, things like that. Ankles get twisted. That's what happens with bigger, faster, stronger people.

So you think you are seeing more injuries as a result of this enhanced size and speed?

I don't know if I'm seeing more injuries; I think the severity of the injuries very often is greater than it used to be. And I think obviously with the bigger, stronger, faster kids, they're better conditioned, so they don't necessarily get injured more, but when they do have an injury, it's very often a significant injury. That's not to say that there still isn't nagging injuries and overuse injuries; those are always going to be around. The good thing about weight training and strength and flexibility and those types of things that they work on, coaches work on, and strength-and-conditioning-type people work with, is it makes the student-athlete better. It gets them better prepared for the activity, which in this case we're talking about football.

... Why did everyone start doing those things that result in the growth? Why did everyone start year-round football? Why did everyone start weightlifting? Why did everyone start speed training?

I've been doing this 20 years, but I think probably during the '90s they started recognizing and realizing -- and when I say "they," I mean the coaches -- that if you worked to make yourself a better football player outside of football season, then it made you a better football player in season, which translates into more wins, which translates into the coaches [being] able to have the success level, and the communities expect this success, and I think now it's snowballed to the point where that's just expected now.

And going back to talking, we were talking about the pressure to win. When you have increased expectations and you have increased pressure, you do things to make sure that those expectations are met. And I think being bigger and faster and stronger as just an athlete will translate into more wins on the football field.

Would you say that most athletic trainers working in high school football teams have proper concussion-management training?

... I know that certified athletic trainers and licensed athletic trainers have to have passed a test, which means they have the educational background to do that. ... It's hard to take a 20-minute online course in concussion management and be able to properly manage concussions. And I think that's what some states would have you believe: "Oh, well, we have this module that we can take online, and that's going to have people understand concussions."

Who would take that?

I think the states that have those modules -- and I believe Texas is one of them -- they would have the coaches or a school nurse or an EMT take the module, and that way they could be concussion-educated. ...

The concussion modules that states will have, state athletic associations, I think they'd like the coaches to take those modules so that they can have some amount of knowledge about concussion management. I think they would also have them available for nurses or EMTs or possibly even team doctors; I don't know. But I think if you don't have any background in concussions and concussion management, you're not going to be able to do well managing a concussion with a 20-minute or less-than-an-hour-long module. ...

What did you think of this recent UIL [University Interscholastic League] decision in Texas to have referees make that decision, ... to let the referee pull someone out of the game for injury?

I don't think that officials are trained to recognize symptoms of a concussion. I think in the absence of anything else, somebody looking to remove ... a student from a game for an injury is better than no one. But if I was at a game and I've got a doctor on the sidelines, and we evaluate a student, and we don't feel that they have a concussion -- possibly they had symptoms for some other reason -- then I would have a hard time with an official telling me that they couldn't go back into the game.

I've had other athletic trainers explain this to me, this line that you walk [between] being too conservative or too liberal. On one hand, I know safety of the players is of utmost importance; on the other hand, you must feel some pressure to get the kids back in, because that's what they are here for, to play football, right?

Well, yeah, the line to walk between holding everybody out and letting everybody play because that's what they want to do, the way I look at it is -- and this is my 28th year to be an athletic trainer -- I want the kids to participate if they can participate, but I'm not going to ever put them back into a game if there's a chance that they can -- whatever injury, whether it be a concussion or a knee or an ankle or a shoulder -- if it can get worse. If we can protect the injury and it may not get better, but it's not going to get worse, then I'm OK with the kid playing. But if he's got an injury that is going to get worse or is going to be a debilitating injury to where he's not going to be able to do his activities of daily living in a week, a month, a year, 10 years, 20 years, I'm not going to let him play.

I don't believe that any high school football game is worth having a shoulder surgery when you're 35 years old or having a knee replacement when you're 40. I don't think that they're that important. I think that the long-term health of the student is what I strive for, not just [to] be able to allow them to play right now.

Are you in a minority?

That's a good question. I don't know if I'm in the minority on that. I think most athletic trainers, they have big-picture skills, and they look, and they're not going to allow a kid to make an injury worse. I mean, that's what we're here for. ...

I hear a lot about playing through pain, though.

Well, it's the old coaches [who] say, "Are you hurt?" or "Are you injured?" I had that very conversation this morning, where at this time of year, this week will be our 12th football game in the last 13 weeks, and if you are at 100 percent right now, where your body has no problems, no bumps, no bruises, no soreness, then you're probably not playing very much. So the kids that play all the time, the starters and the ones that will play 60 or 70 plays a game, are kind of beat up right now. So that's where you would say you're hurt.

But if a kid has a dislocated shoulder that pops out every time he tries to make a tackle, he's injured. I'm not going to let a kid play that's injured. If a kid's hurt, that's where sometimes -- I don't know how to say this without being hard-ass -- but I think the kids that aren't 100 percent but aren't going to get worse, that's their decision to go back and play. If I think -- in my evaluation or in my opinion -- they're not going to worsen an injury and it's not going to be a long-term injury, then I will allow them to play.

It's also part of football, right? It's a violent sport.

Yeah. I mean, football is a collision sport, and when you have a lot of collisions with big people, you get bumps and bruises, and you get injuries. And sometimes it's now about sucking it up and being a man; it's just, can you? If you like playing football and it's a bruise that's not going to get worse, OK.

I feel like it is kind of "Suck it up and be a man." That's what football teaches you. The young man who plays through pain becomes a lesson in surmounting adversity.

A badge of honor, yeah, sure. And that's what you try and teach in all athletics. And I get that. And whether it be football or basketball or baseball, you want to work as a team. Your goal is to be as successful as you can possibly be, state championships or whatever that may be. And we teach all the time that you have to be able to get along with people that you don't necessarily like or that you are like and you have to work through discomfort and pain because -- guess what? -- when you're 25 or 35 or 50 years old, you're going to have times where you have to work with people you don't like, and you may not feel good, and you have to go to work that day because you're supporting your family.

So I think a lot of the lessons that are learned in athletics transfer into real life, and that's why extracurricular activities are so important in our society, in the American society. So getting back to the playing through pain or playing through hurt, I think some of that translates into your long-term outlook on life.

Are you concerned about everything that is happening in the NFL [National Football League]? And not just the NFL. We also see that, for example, the student [Owen Thomas] that committed suicide at the University of Pennsylvania had early evidence of CTE [chronic traumatic encephalopathy] in his brain. This conversation seems to have really kind of [been] taken up nationally. How do you feel about that? Does it surprise you that they found CTE in the brain of a college player who had never reported a concussion? How does that affect your work on the ground?

The amount of media and the amount of information that is coming out about concussions over the last year or two is mind-boggling, really, because for the first 15 or so years of my career, it was just kind of like, "Oh, you got your bell rung, and ha ha," and, "OK, you feel better now; let's go back and practice." And you hear the commentators on TV talk about when they played, the coaches made them go and [get] hit to get their head back right.

The amount of education that has come out about treating closed head injuries over the past couple years is just, it's off the charts, which is really a good thing. ... And what is happening with the NFL and all their education that they've done and the Owen Thomas situation and a lot of the other ones -- I think in Washington state -- what it has done, it has allowed the general public to understand that this is a very serious situation to be dealt with, and it's not to be dealt with lightly.

Do you think the NFL has done enough in educating younger players about this?

I think the NFL is working toward doing enough. I think right now they're reacting in a way that is consistent with early steps of getting to where you need to be. ...

Could they do more?

Could the NFL do more to educate? I don't know what they're doing. ... From the outside, from just a fan, it looks like they're doing the right things right now. They're fining players that are going helmet-to-helmet, and ... they had a video that they produced for all the teams in the league to watch, and I think those are moving toward the right steps.

[What's wrong with referring to an injury as "getting your bell rung"?]

... I think what it does is it lessens the injury. It de-emphasizes the significance of a closed head injury. So I think when you use correct terminology, like "It is a closed head injury," "It is a bruising of the brain," then it brings it home where people understand that it's not something to be laughed off and a day later you're fine.

So that nomenclature has played it down for a while.

I believe so, yes.

Do you think it's going to be hard to change that culture, though?

I think it's hard to change any incorrect assumptions about things, especially when they've been around for so long. The media blitz really over the past 12 to 18 months has really helped a lot. For example, we do, here at our high school, cognitive testing on a computer for all of our football players, and we explain to the kids why we do it, and I talk about it at the parent meeting, and I've had parents this year when their kid had some type of injury or some type of head injury where the parents thought they had a concussion, they asked me to give their student, their son that test again. So I think when they're asking for that test, the education level is getting better and their knowledge of it. They don't understand the injury, but they know that there's steps that need to be taken to take care of it.

That's the opposite of another approach I've heard, where parents will "doctor shop" to find someone to give a clean bill of health.

Doctor shopping happens. There's parents that I think maybe they don't see the long-term significance of an injury. ... Unfortunately, I've had to deal with it here. For example, we had a young man a couple of years ago that had a broken hand, and he went to the orthopedist here in town, and the orthopedist said that you need to have surgery to fix his hand. And Mom and Dad wanted him to be able to finish football season, so they went to enough doctors, and they finally found one that said he didn't have to have surgery. And he was able to finish football season, but he now has a hand that didn't heal right, and he's not going to be able to use it the way it should be, because he's right-hand-dominant, so he can't fully open his fingers on his right hand. And it's unfortunate. And this was a freshman player, so all for playing a freshman football game.

But when parents doctor shop, a lot of times what happens is they learn that if they tell the doctor that my son has X, Y and Z for symptoms that the doctor won't let him participate. So the next doctor they go to, they may only tell him that he has X and Y as the symptoms, and they leave Z out. Then the doctor clears him based on erroneous information.

So let's talk about helmets. Are they advertised correctly? Because I get the impression that some programs may just [have] a little bit of a misperception about what helmets can do.

I think programs understand what helmets can do. I think equipment managers and athletic trainers and coaches for the most part understand what helmets can do. It's the parents that don't.

There's a helmet that's on the market that we use, and it's heavily used in the NFL. ... The Riddell Revolution is the helmet that came out with a lot of fanfare four or five years ago, and it's a good helmet, and Riddell [Football Equipment] has done a lot of research to find out that a lot of concussions, closed head injuries, happen from forces that come from the side and not necessarily from the side and the back. They have extended the helmet; they've made it a little bit better to be able to take blows from the side of the head.

And like I said, there was a lot of fanfare when it first came out, and the parents wanted a concussion-proof helmet. ... Well, there is no such thing as a concussion-proof helmet. It's a good helmet. I think it reduces the number of concussions and the severity of concussions, but it's not concussion-proof. ...

Down here, where we're talking about Texas and Arkansas, heat is a big issue when high school players are practicing. First, are you aware of the heatstroke death in Arkansas this summer?

Yes, there was a heatstroke death in Arkansas this summer. It's unfortunate. They happen. It's very, very sad when that happens. And heatstroke deaths are 100 percent preventable, 100 percent. A school or state has to have some type of guideline and policy to follow to ensure that that doesn't happen.

What would that be? A heat index limit?

Well, there's a lot of issues that go into heat illness. But the NATA, the National Athletic Trainers' Association, had a task force a couple years ago which I was on for preseason practice guidelines, and we came up with a set of guidelines that we felt would help minimize the risk [of] heat-related injuries. And to my knowledge, no states have adopted it yet, but it's only been out about a year.

But basically, getting to your question about a specific heat or a specific heat index or a specific temperature, the higher the temperature gets, the less amount of padding that the athletes need to be wearing. So if it's 100 degrees outside with the heat index -- and the heat index is really not something that we even consider. We go off of what is called the wet bulb globe temperature, which factors in the humidity and the temperature and air and air speed and those kinds of things, and when that gets excessively high, then either the practice needs to cease completely, or they may just need to be in shorts and T-shirt. ...

Do you trust that high school football players self-report concussions?

I think we educate them on the signs and symptoms of concussions, and we ask them to self-report. Now, the kids that are smart know the answers, and if they know that they want to play, they know that if they come and tell me that they've been dizzy and they have headaches and they have trouble sleeping at night, they know that if they come and tell me that, that that's probably going get them off the field. So they may just hope that I don't figure it out.

What we do, though, is a lot of times, it's not the student that comes and tells me; it's one of his friends. They come and say, "Hey, John, he gets headaches in class, and when he gets up from his chair, he is dizzy." So then I go, and that allows me to initiate a dialogue with that particular student.

How many high schools are using the imPACT [Immediate Post-Concussion Assessment and Cognitive Testing] testing?

The number of schools using the imPACT testing I think is growing every year. I've gotten two e-mails just in the last week from athletic trainers saying: "We've kind of resisted this. Our administration resisted this because of the cost, but I've talked them into it, and just how do you go about implementing imPACT at your school?" The number of high schools that are using it is growing all the time. ...